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Risky Business Ischemia Stroke who’s at risk?

Risky Business Ischemia Stroke who’s at risk?. Shaunta Ford-Pierce RN, BSN April 4 th , 2012 Alverno College MSN 621. Tutorial Objectives. Define Ischemic Stroke. Identify modifiable and non-modifiable risk factors, and explain how risk factors can cause stroke to occur.

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Risky Business Ischemia Stroke who’s at risk?

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  1. Risky BusinessIschemia Stroke who’s at risk? Shaunta Ford-Pierce RN, BSN April 4th , 2012 Alverno College MSN 621

  2. Tutorial Objectives • Define Ischemic Stroke. • Identify modifiable and non-modifiable risk factors, and explain how risk factors can cause stroke to occur. • Discuss five main mechanisms of Ischemic Stroke. • Describe the development of atherosclerosis and its relation to ischemic stroke. • Explore teaching strategies and role in prevention of stroke.

  3. Case study • Mr. T is a 52 year-old, African American teacher who was brought to the school nurse’s office by another staff member. The staff member states that Mr. T was complaining of a headache and dizziness. After sitting down at his desk she states “it became hard to understand him and he just didn’t look right.” When the school nurse assessed Mr. T’s awareness he appeared confused and was unable to identify his birthdate and current location. Mr. T becomes weak and begins to slur his speech.

  4. What is Ischemic Stroke? According to the American Stroke Association, Ischemic stroke accounts for about 87% of all stroke cases. (American Stroke Association, 2012) It occurs when there is an “interruption of blood flow in a cerebral vessel” causing damage to parts of the brain tissue and possibly leaving a “neurological deficit”. (Porth & Matfin, 2009)

  5. Test your knowledge Mr. T appears to be having a stroke. What would most likely cause an interruption in blood flow in Ischemic Stroke? Thrombi Correct! “Ischemic strokes are caused by cerebrovascular obstruction by thrombosis or emboli.” (Porth & Matfin, 2009) Head Injury Nice try! However a head injury that leads to a stroke would most likely cause bleeding which would be a hemorrhagic stroke Migraine Nice try! Although migraines have been linked to stroke it is far less common than other causes of blood flow obstruction.

  6. Causes of Ischemic Stroke Ischemic stroke occurs due to blockage of a blood vessel. There are three conditions that contribute to vessel blockage. (Porth & Matfin, 2009)

  7. Etiology of Stroke There are five main mechanisms of ischemic stroke. • Large artery disease • Small vessel or penetrating artery disease • Cardiogenic embolism • Cryptogenic stroke • Other unusual causes such as migraine or vessel dissection. (Porth & Matfin, 2009)

  8. EtiologyLarge vessel Stroke • The Large vessels that are usually involved in ischemic stroke found in the cerebral circulation are the arterial bifurcations. (Porth & Matfin, 2009) • Common sites of origin include, “internal carotid, vertebral arteries and junctions of the basilar and vertebral arteries.” (Porth & Matfin, 2009) Image taken from Wikepedia with permission under Creative Commons Attribution/Share-Alike License 3.0

  9. Small Vessel Stroke (Lacunar Infarct) • Small vessel stroke as known as Lacunar infarcts occur in the deeper, noncortical part of the brain or brain stem (Porth & Matfin, 2009). • Unlike Large Vessel Thrombotic stroke two common causes of Lacunar infarct are microatheroma and lipohylinosis (Porth & Matfin,2009). Lipohylinosis is a small vessel disease “characterized by thickening on he arterial wall” (Wikipedia, 2011). Microatheroma is a build up of plaque on the innermost layer of the wall of an arterty (Miffin, 2007) . • “They result from occlusion of smaller penetrating branches of large arteries” (Porth & Matfin, 2009). • Manifestations of a Lacunar infarct include “ pure motor hemiplegia, pure sensory hemiplegia and dysarthria”(Porth & Matfin, 2009). Because Lacunar infarcts occur in the noncortical part of the brain these manifestations are unique to Lacunar infarct.

  10. Cardiogenic Embolism Stroke • This occurs when a clot or atherosclerotic plaque breaks off a vessel and travels from its origin to the brain, lodging at bifurcations. “Although most cerebral emboli originate from a thrombus in the left heart, they also may originate in an atherosclerotic plaque in the carotid arteries”(Porth &Matfin, 2009) • Conditions that can cause cardiogenic embolism include: rheumatic heart disease, atrial fibrillation, recent heart attack, and bacterial endocarditis. (Porth &Matifin, 2009) • Rheumatic heart disease and bacterial endocarditis can result in valvulardisease such as mitral valve stenosis or mitral valve regurgitation. Valvular disease can disrupt the normal flow of blood throughout the heart causing changes in both the atrium and ventricle (Porth & Matfin, 2009). This leads to alterations in the hemodynamic functions which can cause pooling of blood in the chambers. When blood is stagnant in the heart it increases risk of clot formation which can lead to embolic stroke (Mayo Clinic, 2011).

  11. Cardiogenic Embolism Stroke • “In atrial fibrillation the upper chambers of the heart contract in a very fast and irregular way. As a result, some blood pools in the heart. The pooling increases the risk of blood clots forming in the heart chambers”( National Heart Lung and Blood Institute Explore Stroke, 2011 ). Similar to rheumatic heart disease a blood clot could break off and travel to the brain putting a person with this disorder at greater risk for stroke. • Recent heart attack indicates a predisposition to clotting or atherosclerosis, of which is a causative factor for heart attack. Therefore the client is at a higher risk for recurrence of embolism of blood clot or plaque traveling to the brain causing stroke. • “Embolic stroke usually has a sudden onset with immediate maximum deficit” (Porth & Matfin, 2009).

  12. Cryptogenic stroke • Cryptogenic stroke is when the etiology of stroke cannot be identified. “The classic risk factors for stroke are usually absent and yet cerebral angiography and transesophageal echocardiography do not reveal large-artery occlusive disease or an unequivocal cardioembolic source.” (Catalina et al., 2005)

  13. Test your knowledge! Hemorrhage Sorry that is not correct. Hemorrhage would most likely result in Hemorrhagic Stroke which is caused by a “weakened vessel that ruptures and bleeds into the surrounding brain.” (American Stroke Association, 2012) Name two main mechanisms of ischemic stroke? Large artery Atherosclerotic disease Yes that’s one! Atherosclerosis of the blood vessels causing ischemic stroke is most commonly found in the large vessels i.e.: arterial bifurcations. (Albers, Amarencon, Easton, Sacco, & Teal, 2008) Cardiogenic Embolism Yes That’s right! Remember certain cardiac conditions can predispose a patient to irregular clot formation likely to produce embolic stroke. (Porth & Matfin, 2009)

  14. Test your knowledge What health conditions are likely to cause cardiogenic embolism leading to an ischemic stroke? Atrial fibrillation Yes! “The risk of arterial embolization, particularly stroke, is significantly increased in persons with atrial fibrillation” (Porth & Matfin, 2009). Thrombocytopenia Sorry that is not correct, thrombocytopenia or low platelets can put patients at risk for bleeding therefore it is far more likely that thrombocytopenia could put a patient at risk for hemorrhagic stroke. Rheumatic Heart disease Good job! Mitral valve stenosis is commonly seen in RHD, which can lead to formation of embolism due to impaired filling of left ventricle and atrial distention. As well as irregular heart rhythm (Porth & Matfin, 2009).

  15. Case Study After calling Emergency Medical Services (EMS) to the scene the School Nurse contacts Mr. T’s wife to get a history of any medication or medical conditions that Mr. T may have so that she can inform the EMS team when they arrived. She is told that Mr. T only takes an antihypertensive medication daily with his multivitamin. Mr. T is also a smoker and has a history of a “mini stroke” eight months prior to today.

  16. Risk factors • What factors from Mr. T’s history increase his risk for ischemic stroke? History of Stroke Yes, “The risk of stroke for someone who has already had one is many times that of a person who has not” (American Stroke Association, 2012). Smoker Yes, The nicotine and carbon monoxide in cigarette smoke damage the cardiovascular system such as the endothelium of the blood vessels causing an initial injury to the blood vessel. (American Stroke Association, 2012) Antihypertensive Medication Yes, this is an indication that Mr. T has hypertension which is a risk factor for stroke because of the damage it causes to the blood vessels leading to plaque or atherosclerosis thus increasing risk for stroke. (Porth & Matfin, 2009) Antihypertensive Medication Yes, this is an indication that Mr. T has hypertension which is a risk factor for stroke because of the damage it causes to the blood vessels leading to plaque or atherosclerosis thus increasing risk for stroke. (Porth & Matfin, 2009)

  17. Risk factors • “A risk factor is a condition or behavior that occurs more frequently in those who have, or are at greater risk of getting, a disease than in those who don’t.” (National Institute of Neurological Disorders and Stroke, 2012). • Risk factors for stroke can be divided into two groups modifiable and non-modifiable risk (National Institute of Neurological Disorders and Stroke, 2012). • Modifiable risk factors are things that can be changed or treated (National Institute of Neurological Disorders and Stroke, 2012). • Non-modifiable risk factors are things that cannot be changed (National Institute of Neurological Disorders and Stroke, 2012).

  18. Modifiable vs. Non-Modifiable Modifiable Risk factors Non-Modifiable Risk factors Age Race Gender Family History • High blood pressure • Cigarette smoking • Heart disease • Diabetes • Cholesterol imbalance • Sickle Cell Disease (National Institute of Neurological Disorders and Stroke, 2012)

  19. Modifiable Risk Factors • Sickle cell disease is characterized by sickled blood cells which can cause narrowing of arteries and disrupt blood flow(Porth &Matfin, 2009). • Heart conditions such as “valve defects, irregular heart beat and enlargement of one of the heart’s chambers can result in blood clots” that can travel to the brain. (Porth & Matfin, 2009).

  20. Modifiable Risk factors continued • Atherosclerosis of large and small arteries that supply the brain is the most common cause of ischemic stroke. (Albers, Amarencon, Easton, Sacco, & Teal, 2008) • High blood pressure, smoking, diabetes and cholesterol imbalance (specifically high LDL levels) can all contribute to the development of atherosclerosis. (Porth & Matfin, 2009)

  21. Development of Atherosclerosis • Endothelial Cell injury ; Agents such as smoking, high LDL, and mechanical stress (hypertension) can cause endothelial injury with adhesions of monocytes and platelets. (Porth & Matfin, 2009 ) • Migration of inflammatory cells; inflammatory cells such as monocytes initiate atherosclerotic lesions (Porth & Matfin, 2009 ). • Smooth muscle cell proliferation and lipid deposition (Porth & Matfin, 2009 ). • Development of plaque with lipid core (Porth & Matfin, 2009 ). • Development of atherosclerosis can cause narrowing of the blood vessel which could lead to ischemia. Also plaque hemorrhage or rupture (of plaque) can migrate and lodge in other blood vessels in the brain causing stroke (Porth & Matfin, 2009 ). Image taken from Wikipedia with permission under Creative Commons Attribution/Share-Alike License 3.0 (Porth & Matfin, 2009)

  22. Non-Modifiable Risk Factors • Individual risk doubles for each decade between 55-85 years of age. • “The incidence of stroke increases with age, with men’s stroke incidence rates being greater than women’s at younger ages, but not at older ages” (Porth &Matfin, 2009). • African-Americans are more at risk than any other ethnicity or race. • Family history could be an inherited disposition or “ a common lifestyle among family members”(National Institute of Neurological Disorders and Stroke, 2012). (Porth & Matfin, 2009)

  23. Test your Knowledge True or False: Hypertension, high cholesterol, and cigarette can aid in the development of atherosclerotic vessels. True Correct! These condition can cause initial injury to endothelial walls, initiating several inflammatory responses ultimately causing plaque formation in blood vessels (Porth & Matfin, 2009). False Sorry that is not correct

  24. Test your knowledge! Identify which risk factors are modifiable and non-modifiable. High Fat diet Modifiable High Fat diet Modifiable, because diet modification can lower cholesterol and improve blood pressure which can decrease risk for stroke. Sickle Cell Anemia Modifiable, although sickle cell anemia is an inherited disease it can be treated and managed to lower the risk of stroke. 65 year-old Male Non-modifiable 65 year-old Male Non-modifiable, because gender and age cannot be changed.

  25. Raising awareness • Nurses play a crucial role in the prevention of stroke and raising awareness of risk factors for stroke. • Nurse can influence client lifestyle choices by assessing their belief system which is “essential to the adoption and maintenance of self care before and after stroke.” (Mayo Clinic, 2001-2012) • Empower patients to know their risk for stroke as well as knowing signs and symptoms of stroke to improve the likelihood of seeking medical attention promptly. (Mayo Clinic, 2001-2012)

  26. Summary • Ischemic stroke is an interruption in blood flow to cerebral vessel or vessels subsequently causing damage to brain tissue and neurological deficit (Porth & Matfin, 2009). • Modifiable risk factors for stroke include smoking, heart disease,high blood pressure, cholesterol imbalance and sickle cell disease (National Institute of Neurological Disorders and Stroke, 2012). • Three common mechanisms of ischemic stroke are large artery disease, small vessel disease and cardiogenic embolism(Porth & Matfin, 2009). • Atherosclerosis of a large and small vessels is a common precursor to ischemic stroke (Porth & Matfin, 2009). • Health education and raising awareness about stroke risk is a key component in the prevention of ischemic stroke (Mayo Clinic, 2001-2012).

  27. Literature Cited • Albers, G. W., Amarencon, P., Easton, D. J., Sacco, R. L., & Teal, P. (2008). Antithrombotic and Thrombolytic Therapy for Ischemic Stroke : American College of of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest Journal , 630S-669S. • American Stroke Association. (2012). Ischemic Strokes. Retrieved March 15th, 2012, from www.strokeassociation.org: http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/IschemicClots/Ischemic-Strokes-Clots_UCM_310939_Article.jsp#.T3j1dvBSSSp • Catalina C. Ionita, MD; 1 Andrew R. Xavier, MD; 2 Jawad F. Kirmani, MD; Subasini Dash, MD; 3 Afshin A. Divani, PhD; 2 Adnan I. Qureshi, MD 2. (2005, April 5th). What Proportion of Stroke Is Not Explained by Classic Risk Factors? Retrieved April 3rd, 2012, from Medscape Nurses News: http://www.medscape.com/viewarticle/499978 • Mayo Clinic. Stroke.(2001-2012). Retrieved March 30, 2012, from http://www.mayoclinic.org/medicalprofs/stroke-prevention.html • Miffin, H. (2007). The American Heritage Medical Dictionary. Boston, MA: Houghton Mifflin Company. • National Institutes of Neurological Disorders and Stroke. (2012, January 9th). Brain Basics:Preventing Stroke. Retrieved March 15th, 2012, from National Institutes of Neurological Disorders and Stroke: http://www.ninds.nih.gov/disorders/stroke/preventing_stroke.htm • National Heart Lung and Blood Institute Explore Stroke. (2011, August). What is a Stroke? Retrieved April 22th, 2012, from National Heart Lung and Blood Institute: http://www.nhlbi.nih.gov/health/health-topics/topics/stroke/causes/html • Porth, C. M., & Matfin, G. (2009). Pathophysiology Concepts of Altered Health States 8th Edition. Philadelphia: Wolters Kluwer Health, Lippincott Williams & Wilkins. • Wikipedia. (2011, August 21). Retrieved April 22, 2011, from Lipohyalinosis: http://en.wikipedia.org/wiki/Lipohyalinosis

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